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PAC Assessment Content
• Administrative Content
– Patient Name
– Date of Birth
– Race/Ethnicity
– Marital status
– Admission/Discharge dates
– Admit from/Discharged to locations
– Reason for admission
– Provider NPI, CCN, Medicaid Provider #
• Standardized Patient Assessment
Data Elements (SPADEs) across
instruments
– Function (e.g., self care and mobility)
– Cognitive function (e.g., express &
understand ideas; mental status, such as
depression and dementia)
– Special services, treatments &
interventions (e.g., need for ventilator,
dialysis, chemotherapy, and total
parenteral nutrition)
– Medical conditions and co-morbidities
(e.g., diabetes, heart failure, and pressure
ulcers)
– Impairments (e.g., incontinence; impaired
ability to hear, see, or swallow)
– Other categories
• Clinical Content
– Diagnosis/medical conditions
– Mental/Cognitive Status (memory,
orientation, consciousness, delirium,
mood, behavior)
– Communication (express needs,
understanding verbal/non-verbal content,
hearing and vision)
– Functional Status (Self-care/ADLs,
Mobility, Use of assistive devices)
– Bladder and Bowel continence
– Falls
– Pressure ulcers and other skin conditions
– Surgery
– Nutritional and swallowing status
– Medication information
– Special treatments, procedures &
programs
– Height and Weight
– Patient preferences and goals of
treatment
– Pain
– Vaccinations
– Therapy- PT, OT, SLT
– Living arrangements/support availability
– Care planning